Provider Demographics
NPI:1952019747
Name:FAVORS, TANECIA (RN, CLC)
Entity Type:Individual
Prefix:MRS
First Name:TANECIA
Middle Name:
Last Name:FAVORS
Suffix:
Gender:F
Credentials:RN, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10144 EPPERSON WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10144 EPPERSON WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-3212
Practice Address - Country:US
Practice Address - Phone:619-630-5684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-10
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95265162163W00000X
TX937545163W00000X, 163WL0100X, 163WN1003X
174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No163WN1003XNursing Service ProvidersRegistered NurseNutrition Support